Provider Demographics
NPI:1992136626
Name:PROVIDENT MEMORY CARE GROUP, LLC
Entity type:Organization
Organization Name:PROVIDENT MEMORY CARE GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GAGLIARDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-385-5416
Mailing Address - Street 1:1810 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351-2130
Mailing Address - Country:US
Mailing Address - Phone:936-327-8195
Mailing Address - Fax:
Practice Address - Street 1:1810 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-2130
Practice Address - Country:US
Practice Address - Phone:936-327-8195
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-05
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX137498310400000X
TX102962311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility